Please complete and sign this form and post the original form to: MYCG Pte Ltd

15 Jalan Rumia Holland Village Singapore 277982

A&H Claims Dept AXA Insurance Singapore Pte Ltd 143 Cecil Street #01-01 GB Building Singapore 069542

Dear Sir/Mdm, Duplicate / Certified True Copy Bills/Receipt Submitted Claim Ref. No. : Policy No. : Q0020510 Policyholder : National University of Singapore Insured Person : Lin Kaijie

I am unable to furnish AXA Insurance the original Tax Invoice for my hospitalisation/surgery/medical treatment on 15/07/2011 (date) at NUH (name of hospital/clinic) by (name of doctor, if available). The reason is: I am claiming from another insurer/third party for the same admission/visit. The name of the insurer/third party is . The settlement/payment advice from the said insurer/third party is enclosed. I have lost the bill. I am not claiming from another insurer/third party for the same admission/visit. Other reasons (please state): The hospital only provided me with the duplicated bill and I will not be claiming from another insurer/third party. I declare that the information given is true and complete and that I have not withheld any material information that may influence the assessment of my claim.
Insured Persons Name NRIC No. Signature Date

Lin Kaijie G0566921P

Important Note: Pursuant to the Insurance Act (Cap. 142), you are to disclose in this form fully and faithfully, all facts which you know or ought to know, otherwise, nothing may be payable under the policy.